9908-006 (RPL)LICENSED CONTRACTOR DECLARATION.-
I>.hgreby affirm. under penalty of perjury. that. 1 am, -licensed under provisions of
�Ctii; iter 9 (comencing with Section 7000) of Division 3 of the Business and
Professionals Code; and my License is in full force and effect.
License # Lic. Class Exp. Date
61n92 ('.33 g OI W3122(W
a ate `� Signature of Contractor �� /l - �•� J�
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt 1from the Contractor's
License Law for the following reason: y
(. ) . I, as. owner of the property, or my employees with} wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code). .
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain.a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code,. for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for whichthis
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
CLAR.EEMIGN 1143.
(This section need not be completed if -the permit valuation is for $100.00 or'less).
() I certifythat in the performance of the work for which this permit is issued,
I shall npt employ any person in any manner so as to become subject to the
work r�- compensation laws of California, and agree that if I should become
sub* ct to the workers' compensation provisions of Section 3700 of the Labor
,Qde; I shall forthwith comply with those provisions.
Y,uate: ~" ' "� Applicant
Warning: Failure to secure Work6 s' 'Compensation. co_ verage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree .to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
Zignature
above-mentioned property,for inspection purposes.
(Owner/Agent) X" >.:-+` ' Date •
r
BUILDINGPERMIT PERMIT#{
� r
DATEVALUATION LOT��q TRACT
li •. .
JOB SITE
ADDRESS 52-54SA ENIDA RUBIO
APN f
OWNER
CONTRACTOR / DESIGNER / ENGINEER
LOU LEWIS
BUT, HAVEN' WOLS
.52.545 AVE RUB10
2318 S. VINEYARD MTKUL. SUTITE A
1,A Qt.3IMA CA 922 3
ONTARFO CA 91761
�-N19)tM-7- 6 74 0131.1 _5240
USE OF PERMIT
ANDOR SPA
POOL ONLY. NO UE ATQ,, AL.ARt1 %A1APJ=kS ,S'adEUI HE .IN ISI..JUE, 4,
1''(X1. AN7.; t..R SPA m,(Q.00.1Ls
'
11: SOILkPUt9T993 COST 0'lI? CaN1..►T.p4.1.J7 -.G,AI t�.k.
PERMIT FEE, SUMMARY
PLAN CHECK FIX I: d)x-iMZG-4n-318 599.45
is ,)r.;STR1K-TICYN FEW Ig6_t,N I f -1 `1 gI53.00
EILIC"YtNCAL $4.5.00
PLC►tkfBfNO FEE Pte. ,.. 101; -600 -40 -NO
SI rW-'1'OTA,(: C, ON,";i'kaafCTIC)ti( ANTO MAN C-14ECK
$374.40,
LES PH -Ty IXID FEES
T10'M
"I;(Ya'A6.PERMiTFEES DUE NOW
$041�8,aS�
RECEIPT
DATE _
��
BY
DATE FINALED
INSPECTOR
r-
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts E
Forms & Footings
Ducts f
Slab Grade
Return Air C
Steel
Combustion Air I
Roof Deck
Exhaust Fans I
O.K. to Wrap
F.A.U. I
Framing
Compressor E
Insulation
Vents
Fireplace P.L.
Grills {
Fireplace T.O.
Fans & Controls I
Partv Wall Insulation
Condensate Lines I
Party Wall Firewall
I
Exterior Lath
i
Drywall - Int. Lath
I
i
l
Final [
Final
BLOCKWALL APPROVALS
Set Backs
POOLS - SPAS
Steel
Electric Bond112 J l�
17
Footings
Main Drain I
Bond Beam
Approval to Cover I
Equipment Location [
Underground Electric i
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final {
Water Piping
Plumbing Final I
Plumbing Top Out
Equipment Enclosure [
Shower Pans
O.K. for Finish Plaster i
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
I
Gas Test
I
Appliances
i
Final I
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures -
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
-,.Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS: